Decentralization and health system performance - a focused review of dimensions, difficulties, and derivatives in India

Socioeconomic and geographic inequalities in antenatal and postnatal care components in India, 2016-2021

Despite the well-known importance of high-quality care before and after delivery, not every mother and newborn in India receive appropriate antenatal and postnatal care (ANC/PNC). Using India's National Family Health Surveys (2015-2016 and 2019-2021), we quantified the socioeconomic and geographic inequalities in the utilization of ANC/PNC among women aged 15-49 years and their newborns (N = 161,225 in 2016; N = 150,611 in 2021). For each of the eighteen ANC/PNC components, we assessed absolute and relative inequalities by household wealth (poorest vs. richest), maternal education (no education vs. higher than secondary), and type of place of residence (rural vs. urban) and evaluated state-level heterogeneity. In 2021, the national prevalence of ANC/PNC components ranged from 19.8% for 8 + ANC visits to 91.6% for maternal weight measurement. Absolute inequalities were greatest for ultrasound test (33.3%-points by wealth, 30.3%-points by education) and 8 + ANC visits (13.2%-points by residence). Relative inequalities were greatest for 8 + ANC visits (1.8 ~ 4.4 times). All inequalities declined over time. State-specific estimates were overall consistent with national results. Socioeconomic and geographic inequalities in ANC/PNC varied significantly across components and by states. To optimize maternal and newborn health in India, future interventions should aim to achieve universal coverage of all ANC/PNC components.

How can TB Mukt Panchayat initiative contribute towards ending tuberculosis in India?

Community Engagement (CE) for disease control and health has been tested for a long time across the globe for various health programmes. Realizing the need for true multisectoral action and CE and ownership for ending TB on an accelerated timeline, the Government of India launched a nationwide campaign for 'TB Mukt Panchayat' (meaning 'TB free village council' in Hindi language) on 24 March 2023, banking on the system of local self-governments in the country. Though it is an initiative with huge potential to contribute to India's efforts to end the TB epidemic, it is not without a few shortcomings. We critically analyse the TB Mukt Panchayat initiative and suggest a few recommendations for the way forward.

The Patient's Perspective on the Functioning of the Primary Healthcare Centres in Bangalore, India: An Illustrated Guide

India's healthcare system is, for a large part, organized around a vast network of Primary Healthcare Centres (PHCs) that form the pillar on which the public healthcare sector functions. The World Health Organization (WHO) has emphasized the important role that PHCs play in strengthening community health and the provision of healthcare. Although a few studies have assessed specific elements of services offered by PHCs, only a few have studied the patients' perspectives on the functioning and performance of PHCs in the Indian context. A qualitative research methodology was employed to explore the opinions of 188 patients attending one of three PHCs in Bengaluru (India), using in-depth interviews and thematic analysis. Results showed that patients assessed PHC based on the nine themes that broadly can be classified into components of the center, and that of the personnel. The patients valued the behavioural aspects of the personnel during service delivery and should be configured into the PHC performance.

Data-driven decision-making for district health management: a cluster-randomised study in 24 districts of Ethiopia

BACKGROUND

Use of local data for health system planning and decision-making in maternal, newborn and child health services is limited in low-income and middle-income countries, despite decentralisation and advances in data gathering. An improved culture of data-sharing and collaborative planning is needed. The Data-Informed Platform for Health is a system-strengthening strategy which promotes structured decision-making by district health officials using local data. Here, we describe implementation including process evaluation at district level in Ethiopia, and evaluation through a cluster-randomised trial.

METHODS

We supported district health teams in 4-month cycles of data-driven decision-making by: (a) defining problems using a health system framework; (b) reviewing data; (c) considering possible solutions; (d) value-based prioritising; and (e) a consultative process to develop, commit to and follow up on action plans. 12 districts were randomly selected from 24 in the North Shewa zone of Ethiopia between October 2020 and June 2022. The remaining districts formed the trial's comparison arm. Outcomes included health information system performance and governance of data-driven decision-making. Analysis was conducted using difference-in-differences.

RESULTS

58 4-month cycles were implemented, four or five in each district. Each focused on a health service delivery challenge at district level. Administrators' practice of, and competence in, data-driven decision-making showed a net increase of 77% (95% CI: 40%, 114%) in the regularity of monthly reviews of service performance, and 48% (95% CI: 9%, 87%) in data-based feedback to health facilities. Statistically significant improvement was also found in administrators' use of information to appraise services. Qualitative findings also suggested that district health staff reported enhanced data use and collaborative decision-making.

CONCLUSIONS

This study generated robust evidence that 20 months' implementation of the Data-Informed Platform for Health strengthened health management through better data use and appraisal practices, systemised problem analysis to follow up on action points and improved stakeholder engagement.

TRIAL REGISTRATION NUMBER

NCT05310682.

Development and validation of a minimum requirements checklist for snakebite envenoming treatment in the Brazilian Amazonia

BACKGROUND

Currently, antivenoms are the only specific treatment available for snakebite envenoming. In Brazil, over 30% of patients cannot access antivenom within its critical care window. Researchers have therefore proposed decentralizing to community health centers to decrease time-to-care and improve morbidity and mortality. Currently, there is no evidence-based method to evaluate the capacity of health units for antivenom treatment, nor what the absolute minimum supplies and staff are necessary for safe and effective antivenom administration and clinical management.

METHODS

This study utilized a modified-Delphi approach to develop and validate a checklist to evaluate the minimum requirements for health units to adequately treat snakebite envenoming in the Amazon region of Brazil. The modified-Delphi approach consisted of four rounds: 1) iterative development of preliminary checklist by expert steering committee; 2) controlled feedback on preliminary checklist via expert judge survey; 3) two-phase nominal group technique with new expert judges to resolve pending items; and 4) checklist finalization and closing criteria by expert steering committee. The measure of agreement selected for this study was percent agreement defined a priori as ≥75%.

RESULTS

A valid, reliable, and feasible checklist was developed. The development process highlighted three key findings: (1) the definition of community health centers and its list of essential items by expert judges is consistent with the Brazilian Ministry of Health, WHO snakebite strategic plan, and a general snakebite capacity guideline in India (internal validity), (2) the list of essential items for antivenom administration and clinical management is feasible and aligns with the literature regarding clinical care (reliability), and (3) engagement of local experts is critical to developing and implementing an antivenom decentralization strategy (feasibility).

CONCLUSION

This study joins an international set of evidence advocating for decentralization, adding value in its definition of essential care items; identification of training needs across the care continuum; and demonstration of the validity, reliability, and feasibility provided by engaging local experts. Specific to Brazil, further added value comes in the potential use of the checklist for health unit accreditation as well as its applications to logistics and resource distribution. Future research priorities should apply this checklist to health units in the Amazon region of Brazil to determine which community health centers are or could be capable of receiving antivenom and translate this expert-driven checklist and approach to snakebite care in other settings or other diseases in low-resource settings.

The impact of decentralisation on health systems: a systematic review of reviews

BACKGROUND

Decentralisation is a common mechanism for health system reform; yet, evidence of how it impacts health systems remains fragmented. Despite published findings from primary and secondary research illustrating range of impacts, a comprehensive and clear understanding is currently lacking. This review synthesised the existing evidence to assess how decentralisation (by devolution) impacts each of the six WHO building blocks, and the health system.

METHOD

We systematically searched five electronic databases for reviews exploring impact of decentralisation on health systems, globally. Reviews, both systematic and non-systematic, published in the English language from January 1990 to February 2022 were included. Data were synthesised across each of six building blocks. Quality assessment of the reviews was conducted using Critical Appraisal Skills Program for systematic and Scale for Assessment of Narrative Review Articles for non-systematic reviews.

RESULTS

Nine reviews, each addressing somewhat different questions, contexts and issues, were included. A range of positive and negative impacts of decentralisation on health system building blocks were identified; yet, overall, the impacts were more negative. Although inconclusive, evidence suggested that the impacts on leadership and governance and financing components in particular shape the impact on overall health system. Assessment of how the impact on building blocks translates to the broader impact on health systems is challenged by the dynamic complexities related to contexts, process and the health system itself.

CONCLUSIONS

Decentralisation, even if well intentioned, can have unintended consequences. Despite the difficulty of reaching universally applicable conclusions about the pros and cons of decentralisation, this review highlights some of the common potential issues to consider in advance.

PROSPERO REGISTRATION NUMBER

CRD42022302013.

From electronic health records to clinical management systems: how the digital transformation can support healthcare services

Healthcare systems worldwide are currently undergoing significant transformations in response to increasing costs, a shortage of healthcare professionals and the growing complexity of medical needs among the population. Value-based healthcare reimbursement systems are emerging as an attempt to incentivize patient-centricity and cost containment. From a technological perspective, the transition to digitalized services is intended to support these transformations. A Health Information System (HIS) is a technological solution designed to govern the data flow generated and consumed by healthcare professionals and administrative staff during the delivery of healthcare services. However, the exponential growth of digital capabilities and applied advanced analytics has expanded their traditional functionalities and brought the promise of automating administrative procedures and simple repetitive tasks, while enhancing the efficiency and outcomes of healthcare services by incorporating decision support tools for clinical management. The future of HIS is headed towards modular architectures that can facilitate implementation and adaptation to different environments and systems, as well as the integration of various tools, such as artificial intelligence (AI) models, in a seamless way. As an example, we present the experience and future developments of the European Clinical Database (EuCliD®). EuCliD is a multilingual HIS used by 20 000 nurses and physicians on a daily basis to manage 105 000 patients treated in 1100 clinics in 43 different countries. EuCliD encompasses patients' follow-up, automatic reporting and mobile applications while enabling efficient management of clinical processes. It is also designed to incorporate multiagent systems to automate repetitive tasks, AI modules and advanced dynamic dashboards.

Local government stewardship for TB elimination in Kerala, India

SETTING

The southern Indian state of Kerala has implemented 'Kerala Tuberculosis Elimination Mission' as 'People's Movement against TB' under the stewardship of local governments (LGs). The state has been certified by the Government of India for being on track to attain the UN Sustainable Development Goals related to TB elimination.

OBJECTIVE

To document the role of LG stewardship in the successful implementation of the TB elimination activities in Kerala.

DESIGN

1) Key informant interviews with four state officials, 2) desk review of available documents, 3) in-depth interviews with seven LG leaders, three mid-level programme managers and three health department field staff.

RESULTS

LG involvement led to the establishment of solutions based on local problems, enhanced outreach of services to the socially vulnerable individuals, improved treatment support to patients with TB, increased community ownership of TB elimination activities, reduced TB-related stigma and social determinants being addressed. Institutional mechanisms such as LG TB elimination task forces, formal guidance in planning interventions and appreciation of their performance in the form of awards were facilitators for LG involvement.

CONCLUSION

LG stewardship can accelerate TB elimination. A good plan for engagement and institutional mechanisms are crucial for LG involvement.

Re-engineering primary healthcare in Kerala

INTRODUCTION

In the backdrop of the Sustainable Development Goals (SDGs), the state of Kerala, India, revamped its existing primary health centres (PHCs) into people-friendly family health centres (FHCs) in order to provide comprehensive primary care as part of a mission-based ('Aardram') initiative. It was envisioned that the mission's implementation and operation would make use of decentralised governance. The present study explored how the decentralised governance influenced reorganisation of primary care.

METHODS

The study adopted an exploratory approach using qualitative methods: key informant interviews (n = 8), in-depth interviews (n = 20) and document reviews. Thematic analysis was done following deductive coding and the themes that emerged were organised under a schema.

RESULTS

The results could be summarised under five overarching themes. Strong political commitment, combined with bureaucratic competence, facilitated implementation and functioning of 'Aardram' primary care. The insights developed through multi-sectoral training helped local governments (LGs) get involve and engage with the health system as a team in order to plan and implement interventions. The decentralised governance structures enabled re-engineering of PHCs by mobilisation of financial resources, provision of human resources, infrastructure modification, and enhanced community participation at various levels. Non-uniformity of commitment, sub-optimal engagement of urban LGs and issues of sustainability and monitoring were the shortcomings observed.

CONCLUSION

Decentralised governance played a positive role in the re-engineering of PHCs, which was utilised as a platform to demonstrate best practices in health governance through a participatory approach. The importance of empowering LGs through capacity building to address challenges in achieving primary care SDGs is highlighted in this study.

Of primary health care reforms and pandemic responses: understanding perspectives of health system actors in Kerala before and during COVID-19

BACKGROUND

In 2016, the Government of the southern Indian state of Kerala launched the Aardram mission, a set of reforms in the state's health sector with the support of Local Self Governments (LSG). Primary Health Centres (PHCs) were slated for transformation into Family Health Centres (FHCs), with extended hours of operation as well as improved quality and range of services. With the COVID-19 pandemic emerging soon after their introduction, we studied the outcomes of the transformation from PHC to FHC and how they related to primary healthcare service delivery during COVID-19.

METHODS

A qualitative study was conducted using In-depth interviews with 80 health system actors (male n = 32, female n = 48) aged between 30-63 years in eight primary care facilities of four districts in Kerala from July to October 2021. Participants included LSG members, medical and public health staff, as well as community leaders. Questions about the need for primary healthcare reforms, their implementation, challenges, achievements, and the impact of COVID-19 on service delivery were asked. Written informed consent was obtained and interview transcripts - transliterated into English-were thematically analysed by a team of four researchers using ATLAS.ti 9 software.

RESULTS

LSG members and health staff felt that the PHC was an institution that guarantees preventive, promotive, and curative care to the poorest section of society and can help in reducing the high cost of care. Post-transformation to FHCs, improved timings, additional human resources, new services, fully functioning laboratories, and well stocked pharmacies were observed and linked to improved service utilization and reduced cost of care. Challenges of geographical access remained, along with concerns about the lack of attention to public health functions, and sustainability in low-revenue LSGs. COVID-19 pandemic restrictions disrupted promotive services, awareness sessions and outreach activities; newly introduced services were stopped, and outpatient numbers were reduced drastically. Essential health delivery and COVID-19 management increased the workload of health workers and LSG members, as the emphasis was placed on managing the COVID-19 pandemic and delivering essential health services.

CONCLUSION

Most of the health system actors expressed their belief in and commitment to primary health care reforms and noted positive impacts on the clinical side with remaining challenges of access, outreach, and sustainability. COVID-19 reduced service coverage and utilisation, but motivated greater efforts on the part of both health workers and community representatives. Primary health care is a shared priority now, with a need for greater focus on systems strengthening, collaboration, and primary prevention.

Health system-related barriers to prenatal care management in low- and middle-income countries: a systematic review of the qualitative literature

BACKGROUND

Appropriate prenatal care (PNC) is essential for improving maternal and infant health; nevertheless, millions of women in low- and middle-income countries (LMICs) do not receive it properly. The objective of this review is to identify and summarize the qualitative studies that report on health system-related barriers in PNC management in LMICs.

METHODS

This systematic review was conducted in 2022. A range of electronic databases including PubMed, Web of Knowledge, CINHAL, SCOPUS, Embase, and Science Direct were searched for qualitative studies conducted in LMICs. The reference lists of eligible studies also were hand searched. The studies that reported health system-related barrier of PNC management from the perspectives of PNC stakeholders were considered for inclusion. Study quality assessment was performed applying the Critical Appraisal Skills Programme (CASP) checklist, and thematic analyses performed.

RESULTS

Of the 32 included studies, 25 (78%) were published either in or after 2013. The total population sample included 1677 participants including 629 pregnant women, 122 mothers, 240 healthcare providers, 54 key informed, 164 women of childbearing age, 380 community members, and 88 participants from other groups (such as male partners and relatives). Of 32 studies meeting inclusion criteria, four major themes emerged: (1) healthcare provider-related issues; (2) service delivery issues; (3) inaccessible PNC; and (4) poor PNC infrastructure.

CONCLUSION

This systematic review provided essential findings regarding PNC barriers in LMICs to help inform the development of effective PNC strategies and public policy programs.

Promoting the culture of key performance indicators (KPIs) among primary health care staff at health district level: An intervention study

Recently, identifying performance indicators and developing measurement frameworks have become crucial concerns. Our study first sought to analyze service statistics of Primary Health Care (PHC) facilities for the years 2017 and 2018 to develop PHC key performance indicators (KPI).This was then followed by a thorough discussion of these KPIs with staff and service providers. Finally, re-rating these PHC (KPI) changes by analyzing service statistics infographs for 2017 and 2018 relative to 2019. El-Aiat Health District-Giza Governorate and its 15 PHC facilities served as the study's setting. A quasi-experimental intervention design was used based on operation research with quantitative and qualitative data analysis. The pre-test consisted of a mathematical analysis of service and vital statistics for 2017 and 2018 to calculate composite indices and create infographs (simple colored matrices) for these indices. The intervention included two discussion meetings (2 h each). It included reviewing the Performance Knowledge Matrices (infographs) with the service providers for subsequent problem specification, solving, and suggestion extraction to enhance performance. The SWOC (Strengths, Weaknesses, Opportunities, and Challenges) framework was used to analyze the qualitative data extracted from these conversations. Among the identified flaws were a deficiency in the number of physicians and nurses, inadequate training, insufficient work environments, and a lack of moral appreciation and recognition for the staff. The proposed solutions include providing health education services by nurses and follow-up services in certain units via home visits and mobile clinics. Post-test also entailed analyzing service and vital statistics for 2019 and redisplaying KPI infographics. Four of fifteen PHC facilities achieved a positive response based on the staff-suggested info-action-based intervention, according to our findings after comparing data for the pre-intervention and post-intervention periods of 2017-2018 and 2019. We concluded that reviewing the information derived from the "knowledge performance colored matrix" inspired district and PHC service providers to identify their weaknesses (avoided them as much as possible) and their strengths (practiced the solutions they suggested themselves) in the meetings which eventually improved their performance. Ultimately, the outcome scores and impact indicators of the provided PHC services were enhanced.

Evaluation of health managers' opinions about decentralization in health services

OBJECTIVE

It was aimed to determine the opinions of health-care managers on theimplementation of decentralization in health-care services.

METHODS

The research is a cross-sectional and descriptive study.Sample of the study included 261 health managers.Research data were collected from health-care managers between June 8 and July 17, 2020, using face-to-face interviews technic by a questionnaire, in an average of 20-25 minutes. The obtained data were transferred to the computer environment and analyzed with the number, percentage, and Chi-square tests.

RESULTS

About 52.5% of the health managers stated that health-care services should be provided by the public, 63.2% of them stated that health-care services should be a form of empowered decentralization, 41.8% of them stated that decentralization could be successful in Turkiye, 62.6% stated that decentralization would provide flexibility in health-care management, 70.3% of them said that it could find solutions to the problems, and 73.3% of them stated that it will improve employee performance whereas 44.9% of them stated that it would negatively affect providing services in integrity, 67.2% of them stated that it would cause regional inequalities, 73.2% of them said that local factors will intervene in health-care services, and 57.9% reported that it would weaken the central power.

CONCLUSION

The majority of health-care managers prefer that health-care services are provided by the public health-care service and prefer the empowered decentralization of health-care services. More than half of the health-care managers expressed their positive views such as the fact that decentralization provides flexibility in health-care services, improve the performance, and participation in service along with the negative views such as the fact that decentralization negatively affects the service delivery, causes regional inequalities and intervention of local factors, and weakens the central power.

Mobile Health and Nutrition Team Service Implementation in Somali and Afar Regions of Ethiopia: A Qualitative Implementation Science Study

Background

Ethiopia has been implementing Mobile Health and Nutrition Teams (MHNTs) to improve the accessibility of essential healthcare services for unreached populations with poor infrastructure to ensure health for all target by Universal health coverage (UHC). However, the current implementation status of this MNHT is not assessed.

Objective

This study aimed to capture the current implementation status of the MHNT from the program managers, supporting partners and decision makers at each level of the health system structure in Afar and Somali regions.

Methods

We conducted qualitative study with phenomenological study design. The data was collected from RHB MHNT coordinator, woreda health office MHNT coordinator, MHNT leader and representatives from implementing partners. The interview guides were developed using the CFIR framework.

Results

Out of the 17 respondents, 13 responded all the standard service packages a MHNT is expected to deliver (76.5%). Overall, the KIIs mentioned that the MHNTs are effective in ensuring access and quality of health services. MHNT strategy has high demand and acceptability by the community and the service providers. The main barrier to program implementation is the gap in service integration within and across sectors. Inadequate staffing of the MHNT, gaps in ensuring proper professional mix, frequent turnover of contract health workers, and skill gaps hamper effective and sustainable implementation of the program.

Conclusion

MHNT establishment, effectiveness, acceptability and sustainably in the implementing woredas of Afar and Somali Regions is very promising. The culture of MHNT documentation and reporting needs some improvement. Besides, community engagement and government ownership are good drivers for sustainability of MHNT. Standardizing and adding additional professionals with capacity building is crucial to ensuring service quality. Furthermore, community mobilization and woreda leadership commitment boosting will be needed for granting sustainability. Finally, national scale up of this alternative strategy is recommended through standardized implementation modality.

EFFECTS OF RESTRICTION MEASURES ON MORBIDITY AND MORTALITY IMPLEMENTED DURING COVID-19 PANDEMIC IN TURKEY: A RESEARCH THROUGH NATIONAL DATA INCLUDING ONE YEAR

This research is aimed to determine effects of restriction measures implemented in Turkey during COVID 19 pandemic throughout detecting variations in the “number of cases daily”, “test positivity rate daily”, and “number of death daily” according to different restriction periods. In order to be able to analyze on the basis of cases declared as standard, the periods of restriction measures between November 18, 2020 and November 17, 2021 were included in the research. The data of the Ministry of Health was used as the source. When making statistical assessment for the "number of cases per day" and the "test positivity rate per day", we evaluated each restriction period to cover the first 10 days after the end of this period. When comparing the “daily death numbers”, we evaluated each restriction period to include the daily death numbers for the first 21 days after the end of that period. The highest means were seen for all three parameters examined during “revised local decision-making phase”. These mean are 57,396 for number of cases per day, 18.4 for test positivity rate per day, 351 for number of deaths per day. This period is the only period in which the means for "number of cases" and "number of deaths" are higher than the first period, which is the reference period, and for these parameters, a statistically significant difference is detected with the reference period (p

The quest for accountability of Health Facility Governing Committees implementing Direct Health Facility Financing in Tanzania: A supply-side experience

User committees, such as Health Facility Governing Committees, are popular platforms for representing communities and civil society in holding service providers accountable. Fiscal decentralization via various arrangements such as Direct Health Facility Financing is thought to strengthen Health Facility Governing Committees in improving accountability in carrying out the devolved tasks and mandates. The purpose of this study was to analyze the status of accountability of Health Facility Governing Committees in Tanzania under the Direct Health Facility Financing setting as perceived by the supply side. In 32 different health institutions, a cross-sectional design was used to collect both qualitative and quantitative data at one point in time. Data was collected through a closed-ended questionnaire, an in-depth interview, and a Focus Group Discussion. Descriptive statistics, multiple logistic regression, and theme analysis were used to analyze the data. According to the findings, Health Facility Governing Committees' accountability is 78%. Committees have a high level of accountability in terms of encouraging the community to join community health funds (91.71%), receiving medicines and medical commodities (88.57%), and providing timely health services (84.29%). The health facility governance committee's responsibility was shown to be substantially connected with the health planning component (p = 0.0048) and the financial management aspect (p = 0.0045). This study found that the fiscal decentralization setting permits Committees to be accountable for carrying out their obligations, resulting in improved health service delivery in developing nations.

Effects of Hospital Decentralization Processes on Patients’ Satisfaction: Evidence from Two Public Romanian Hospitals across Two Decades

Patient satisfaction represents an essential indicator in assessing healthcare quality, as it is an extensive source of information regarding the healthcare provider’s ability to meet patients’ expectations and is a key predictor of patients’ behavioral approaches. The purpose of this study is to evaluate the degree of satisfaction of patients who have been admitted for inpatient hospitalization in two public hospitals located in the North-West of Romania, during two different periods of administration/management of healthcare services, in the context of an ongoing decentralization process of public healthcare services (initiated in 2010). An exploratory study was conducted in the period of April–December 2021, based on a patient satisfaction survey, through which the quality of in-hospital services was evaluated at present and up until 2010, by the hospitalized patients in both periods. In total, 208 survey responses were validated and analyzed. The chi-square test and t-test were used for statistical processing. The results of the survey revealed that the percentage of patients that evaluated the inpatient experience as excellent was significantly higher during the period when hospitals were administered by local authorities than during the period of centralized administration (68.27% vs. 28.37%; p < 0.001), both in medical care as well as in hospital hotel services (71.63 vs. 29.81%), respectively (56.25 vs. 27.40; p < 0.001). The results obtained from this survey indicate that the decentralization of hospital units has had a positive effect on the quality of inpatient medical services and highlight the need for formulating and finalizing a policy aimed at developing and enhancing medical services.

SPARC the Change: What the Strategic Purchasing Africa Resource Center Has Learned about Improving Strategic Health Purchasing in Africa

Embodied in the goals of universal health coverage (UHC) are societal norms about ethics, equity, solidarity, and social justice. As African countries work toward UHC, it is important for their governments to use all available resources, knowledge, and networks to continue to bring this goal closer to reality for their populations. The Strategic Purchasing Africa Resource Center (SPARC) was established in 2018 as a "go-to" source of Africa-based expertise in strategic health purchasing, which is a critical policy tool for making more effective use of limited funds for UHC. SPARC facilitates collaboration among governments and research partners across Africa to fill gaps in knowledge on how to make progress on strategic purchasing. The cornerstone of this work has been the development and use of the Strategic Health Purchasing Progress Tracking Framework to garner insights from each country's efforts to make health purchasing more strategic. Application of the framework and subsequent dialogue within and between countries generated lessons on effective purchasing approaches that other countries can apply as they chart their own course to use strategic purchasing more effectively. These lessons include the need to clarify the roles of purchasing agencies, define explicit benefit packages as a precondition for other strategic purchasing functions, use contracting to set expectations, start simple with provider payment and avoid open-ended payment mechanisms, and use collaborative rather than punitive provider performance monitoring. SPARC has also facilitated learning on the "how-to" and practical steps countries can take to make progress on strategic purchasing to advance UHC.

Precision mapping child undernutrition for nearly 600,000 inhabited census villages in India

There are emerging opportunities to assess health indicators at truly small areas with increasing availability of data geocoded to micro geographic units and advanced modeling techniques. The utility of such fine-grained data can be fully leveraged if linked to local governance units that are accountable for implementation of programs and interventions. We used data from the 2011 Indian Census for village-level demographic and amenities features and the 2016 Indian Demographic and Health Survey in a bias-corrected semisupervised regression framework to predict child anthropometric failures for all villages in India. Of the total geographic variation in predicted child anthropometric failure estimates, 54.2 to 72.3% were attributed to the village level followed by 20.6 to 39.5% to the state level. The mean predicted stunting was 37.9% (SD: 10.1%; IQR: 31.2 to 44.7%), and substantial variation was found across villages ranging from less than 5% for 691 villages to over 70% in 453 villages. Estimates at the village level can potentially shift the paradigm of policy discussion in India by enabling more informed prioritization and precise targeting. The proposed methodology can be adapted and applied to diverse population health indicators, and in other contexts, to reveal spatial heterogeneity at a finer geographic scale and identify local areas with the greatest needs and with direct implications for actions to take place.

Obstetrics Nursing and Medical Health System Based on Blockchain Technology

Blockchain, as an emerging force transforming the Internet, has applications in finance, logistics, public services, and other fields. It will also have a huge impact on the medical and health industry. The salient features of blockchain technology include guaranteeing information security and user privacy, decentralization, without the involvement of third-party trust institutions, and being able to establish a high-value input and output two-way system, which has a very important application space in obstetric care, medical, and health. The traditional medical and health system is far from being able to meet the information exchange between doctors and individuals. Therefore, building an interconnected obstetric care and health system based on blockchain technology is the direction of future obstetric care and medical development. This paper has conducted an in-depth study of the obstetric care medical health system, with the help of the Internet of Things, blockchain, and other technical means; the purpose is to realize the sharing and security of medical data and to break the limitations of traditional user information. This paper builds a medical electronic health record system model and a hybrid consensus model based on blockchain technology to realize the safety and transparency of patients' personal medical information data and achieve two-way communication and interconnection of information between doctors and patients. This paper analyzes the current status of domestic and foreign medical and health systems and the blockchain-based medical electronic health record system. It is concluded that the domestic investment in medical and health in 2018 was as high as 113.2 billion yuan, and the entire investment scale is continuously expanding. Pay attention to the health system. In the future, the obstetric care and medical health system based on blockchain technology will surely be realized and improved.

Surgical Unmet Need in a Low-Income Area of a Metropolitan City in India: A Cross-Sectional Study

INTRODUCTION

We investigated the burden of surgical conditions, level of unmet needs and reasons for non-utilization of surgical services in a slum of Ahmedabad, India.

METHODS

A community-based cross-sectional study was carried out from August to December 2019. Inclusion criteria was age > 14 years; any type of injury/condition that requires surgery; subject has had surgery in last 1 year, and death information of family members. Data were stored and coded in Microsoft excel and exported to IBM SPSS statistics version 25 software for data analysis. Frequencies and proportions (categorical variable) are used to summarize utilization of surgical services and understanding surgical need. The Surgeons Overseas Assessment of Surgical was used to identify surgical met and unmet needs translated into local language. Open Data Kit software was used to install questionnaire in the "Tablet" to collect information and stress-free workflow in field.

RESULTS

Out of 10,330 population in 2066 households, 7914 were more than 14 years of age. 3.46% (n = 274) people needed surgery; 116 did not avail surgery and were categorized in "unmet need." Fifty percent of individuals with surgical needs had abdominal- or extremities-related problems followed by eyes surgery need (14%); back, chest and breast surgical need was 13.5%. Seventeen percent of participants with surgical needs had wounds related to injury or accident while 63% had wounds that were not related to injury. Almost all participants had gone to a physician to seek healthcare, however 42% did not avail surgical care needed for a variety of reasons. Forty-six percent of participants needing surgical care underwent major surgical procedure, while 11% had minor procedures. Financial reasons (34.5%) and lack of trust (35.3%) were major reasons for not availing surgical care.

CONCLUSIONS AND RELEVANCE

Ahmedabad is a relatively high income metropolitan city, has universally free health care and multiple healthcare facilities. Despite this, we have shown that there is significant unmet need for surgical procedures in the low-income population. A unique finding was that most patients sought a consultation but approximately 50% did not avail of the free surgical procedures under the universally free health care system in this city. We propose creation of community healthcare workers focused on surgical conditions.

Place of the periodic medical check-up in basic health care in Tunisia

The objective of primary health care is to reduce mortality and morbidity. This kind of care was very efficient in communicable diseases, malnutrition and maternal and neonatal diseases; however, their impact on non communicable diseases and mental disorders control is not obvious. In Tunisia, primary health care was introduced in the early 1980s; a lot of progress were notified in particular in health of mothers and children in particular, but only slightly in non communicable diseases control and mental health promotion. Therefore, a new approach would be strongly recommended to remedy this situation. The Medical Periodic Check-up (MPC) implemented in North America would have a positive impact in the prevention and management of non communicable diseases. What would be the place of this MPC in primary health care in Tunisia? The MPC has two main objectives: the prevention of specific diseases and health promotion. However, despite its efficiency and usefulness, the MPC could be costly, especially for countries with limited resources. Current evidence suggests that the most appropriate approach would be to take periodic preventive health visits tailored to the level of risk. The frequency of visits depends on the age, sex and state of health of the individual. In conclusion, there are strong arguments in favor of the introduction of MPC in primary health care in Tunisia, especially among adults in non communicable diseases control strategy. However, it's highly be recommended that the BMC should be oriented according to the risk levels in order to optimize resources. It is also important to educate and the public, especially women and young adults, to benefit from periodic medical and dental examinations.

"There Is No Link Between Resource Allocation and Use of Local Data": A Qualitative Study of District-Based Health Decision-Making in West Bengal, India

BACKGROUND

Effective coordination among multiple departments, including data-sharing, is needed for sound decision-making for health services. India has a district planning process involving departments for local resource-allocation based on shared data. This study assesses the decision-making process at the district level, with a focus on the extent of local data-use for resource allocation for maternal and child health.

METHODS

Direct observations of key decision-making meetings and qualitative interviews with key informants were conducted in two districts in the State of West Bengal, India. Content analysis of the data maintained within the district health system was done to understand the types of data available and sharing mechanisms. This information was triangulated thematically based on WHO health system blocks.

RESULTS

There was no structured decision-making process and only limited inter-departmental data-sharing. Data on all 21 issues discussed in the district decision-making meetings observed were available within the information systems. Yet indicators for only nine issues-such as institutional delivery and immunisation services were discussed. Discussions about infrastructure and supplies were not supported by data, and planning targets were not linked to health outcomes.

CONCLUSION

Existing local data is highly under-used for decision-making at the district level. There is strong potential for better interaction between departments and better use of data for priority-setting, planning and follow-up.

Do social accountability approaches work? A review of the literature from selected low- and middle-income countries in the WHO South-East Asia region

Governance failures undermine efforts to achieve universal health coverage and improve health in low- and middle-income countries by decreasing efficiency and equity. Punitive measures to improve governance are largely ineffective. Social accountability strategies are perceived to enhance transparency and accountability through bottom-up approaches, but their effectiveness has not been explored comprehensively in the health systems of low- and middle-income countries in south and Southeast Asia where these strategies have been promoted. We conducted a narrative literature review to explore innovative social accountability approaches in Bangladesh, Bhutan, India, Indonesia, the Maldives, Myanmar and Nepal spanning the period 2007-August 2017, searching PubMed, Scopus and Google Scholar. To augment this, we also performed additional PubMed and Google Scholar searches (September 2017-December 2019) to identify recent papers, resulting in 38 documents (24 peer-reviewed articles and 14 grey sources), which we reviewed. Findings were analysed using framework analysis and categorized into three major themes: transparency/governance (eight), accountability (11) and community participation (five) papers. The majority of the reviewed approaches were implemented in Bangladesh, India and Nepal. The interventions differed on context (geographical to social), range (boarder reform to specific approaches), actors (public to private) and levels (community-specific to system level). The initiatives were associated with a variety of positive outcomes (e.g. improved monitoring, resource mobilization, service provision plus as a bridge between the engaged community and the health system), yet the evidence is inconclusive as to the extent that these influence health outcomes and access to health care. The review shows that there is no common blueprint which makes accountability mechanisms viable and effective; the effectiveness of these initiatives depended largely on context, capacity, information, spectrum of actor involvement, independence from power agendas and leadership. Major challenges that undermined effective implementation include lack of capacity, poor commitment and design and insufficient community participation.

Health system reforms in China a half century apart: Continuity but adaptation

Well-functioning governance arrangements are an essential, but often overlooked or poorly understood contributor to high quality health systems. Yet governance systems are embedded in institutional structures and shaped by cultural norms that can be difficult to change. We look at a country that has implemented two major health system reforms separated by half a century during which it has undergone remarkable political, economic, and social change. These are the Chinese Patriotic Health Campaign (PHC), beginning in the 1950s, and the New Cooperative Medical Scheme (NCMS), in the 2000s. We use these as case studies to explore how governance arrangements supported the design and implementation of policies implemented on a large scale in these quite different contexts. Drawing on review of archival documents, published literature, and semi-structured interviews with key policy makers, we conclude that few aspects of governance underwent fundamental changes. In both periods, the policy design stage included encouragement of sub-national tiers of government to pilot policy options, accumulate evidence, and disseminate it to others facing similar challenges, all facilitated by clear lines of accountability and a willingness by those at the top of the hierarchy to learn lessons from lower levels. At the implementation stage, rapid scaling up benefitted from leadership by national institutions that could enact regulations and set policy goals and targets for lower tiers of government, evaluating the performance of local government officers in terms of their ability to implement policy, while encouraging local government to pilot innovative measures. These findings highlight the importance of a detailed understanding of governance and how it is shaped by context, demonstrating continuity over long periods even at times of major social, political, and economic change. This understanding can inform future policy development in China and measures to strengthen governance aspects of reforms elsewhere.

Application of evidence-informed deliberative processes in health technology assessment in low- and middle-income countries

OBJECTIVES

Evidence-informed deliberative processes (EDPs) were introduced to guide health technology assessment (HTA) agencies to improve their processes toward more legitimate decision making. A survey among members of the International Network of Agencies for HTA (INAHTA) showed that EDPs can also be relevant for countries that have not (yet) established such an agency. Therefore, we explored to what extent low- and middle-income countries (LMIC) applied the steps and elements stipulated in the EDP framework and their need for guidance.

METHODS

The survey among INAHTA members was slightly adapted to address LMIC context and sent to 416 experts identified through several HTA sources. The questions focused on contextual factors and the EDP steps (installation of an appraisal committee, selecting technologies and criteria, assessment, appraisal, communication and appeal). Data collection took place between 21 May and 1 September 2019. Descriptive statistics and qualitative analyses were used to summarize the findings.

RESULTS

We received sixty-six meaningful responses from experts in thirty-two LMIC. We found that contextual factors to support HTA development are overall not present or only present to some extent. Respondents indicated that guidance was needed for specific elements related to selecting technologies and criteria, assessment, appraisal, as well as communication and appeal.

CONCLUSIONS

EDPs have the potential to provide steps for improving HTA processes. The results of this study can serve as a baseline measurement for future monitoring and evaluation of EDP application in the responding LMIC. This could support the countries in improving their processes and enhancing legitimate decision making when using HTA.

The influence of corruption and governance in the delivery of frontline health care services in the public sector: a scoping review of current and future prospects in low and middle-income countries of south and south-east Asia

BACKGROUND

The dynamic intersection of a pluralistic health system, large informal sector, and poor regulatory environment have provided conditions favourable for 'corruption' in the LMICs of south and south-east Asia region. 'Corruption' works to undermine the UHC goals of achieving equity, quality, and responsiveness including financial protection, especially while delivering frontline health care services. This scoping review examines current situation regarding health sector corruption at frontlines of service delivery in this region, related policy perspectives, and alternative strategies currently being tested to address this pervasive phenomenon.

METHODS

A scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was conducted, using three search engines i.e., PubMed, SCOPUS and Google Scholar. A total of 15 articles and documents on corruption and 18 on governance were selected for analysis. A PRISMA extension for Scoping Reviews (PRISMA-ScR) checklist was filled-in to complete this report. Data were extracted using a pre-designed template and analysed by 'mixed studies review' method.

RESULTS

Common types of corruption like informal payments, bribery and absenteeism identified in the review have largely financial factors as the underlying cause. Poor salary and benefits, poor incentives and motivation, and poor governance have a damaging impact on health outcomes and the quality of health care services. These result in high out-of-pocket expenditure, erosion of trust in the system, and reduced service utilization. Implementing regulations remain constrained not only due to lack of institutional capacity but also political commitment. Lack of good governance encourage frontline health care providers to bend the rules of law and make centrally designed anti-corruption measures largely in-effective. Alternatively, a few bottom-up community-engaged interventions have been tested showing promising results. The challenge is to scale up the successful ones for measurable impact.

CONCLUSIONS

Corruption and lack of good governance in these countries undermine the delivery of quality essential health care services in an equitable manner, make it costly for the poor and disadvantaged, and results in poor health outcomes. Traditional measures to combat corruption have largely been ineffective, necessitating the need for innovative thinking if UHC is to be achieved by 2030.

National, regional, and state-level all-cause and cause-specific under-5 mortality in India in 2000-15: a systematic analysis with implications for the Sustainable Development Goals

BACKGROUND

India had the largest number of under-5 deaths of all countries in 2015, with substantial subnational disparities. We estimated national and subnational all-cause and cause-specific mortality among children younger than 5 years annually in 2000-15 in India to understand progress made and to consider implications for achieving the Sustainable Development Goal (SDG) child survival targets.

METHODS

We used a multicause model to estimate cause-specific mortality proportions in neonates and children aged 1-59 months at the state level, with causes of death grouped into pneumonia, diarrhoea, meningitis, injury, measles, congenital abnormalities, preterm birth complications, intrapartum-related events, and other causes. AIDS and malaria were estimated separately. The model was based on verbal autopsy studies representing more than 100 000 neonatal deaths globally and 16 962 deaths among children aged 1-59 months at the subnational level in India. By applying these proportions to all-cause deaths by state, we estimated cause-specific numbers of deaths and mortality rates at the state, regional, and national levels.

FINDINGS

In 2015, there were 25·121 million livebirths in India and 1·201 million under-5 deaths (under-5 mortality rate 47·81 per 1000 livebirths). 0·696 million (57·9%) of these deaths occurred in neonates. There were disparities in child mortality across states (from 9·7 deaths [Goa] to 73·1 deaths [Assam] per 1000 livebirths) and regions (from 29·7 deaths [the south] to 63·8 deaths [the northeast] per 1000 livebirths). Overall, the leading causes of under-5 deaths were preterm birth complications (0·330 million [95% uncertainty range 0·279-0·367]; 27·5% of under-5 deaths), pneumonia (0·191 million [0·168-0·219]; 15·9%), and intrapartum-related events (0·139 million [0·116-0·165]; 11·6%), with cause-of-death distributions varying across states and regions. In states with very high under-5 mortality, infectious-disease-related causes (pneumonia and diarrhoea) were among the three leading causes, whereas the three leading causes were all non-communicable in states with very low mortality. Most states had a slower decline in neonatal mortality than in mortality among children aged 1-59 months. Ten major states must accelerate progress to achieve the SDG under-5 mortality target, while 17 are not on track to meet the neonatal mortality target.

INTERPRETATION

Efforts to reduce vaccine-preventable deaths and to reduce geographical disparities should continue to maintain progress achieved in 2000-15. Enhanced policies and programmes are needed to accelerate mortality reduction in high-burden states and among neonates to achieve the SDG child survival targets in India by 2030.

FUNDING

Bill & Melinda Gates Foundation.

Health System Outcomes in BRICS Countries and Their Association With the Economic Context

The aim of the article is to compare health system outcomes in the BRICS countries, assess the trends of their changes in 2000−2017, and verify whether they are in any way correlated with the economic context. The indicators considered were: nominal and per capita current health expenditure, government health expenditure, gross domestic product (GDP) per capita, GDP growth, unemployment, inflation, and composition of GDP. The study covered five countries of the BRICS group over a period of 18 years. We decided to characterize countries covered with a dataset of selected indicators describing population health status, namely: life expectancy at birth, level of immunization, infant mortality rate, maternal mortality ratio, and tuberculosis case detection rate. We constructed a unified synthetic measure depicting the performance of individual health systems in terms of their outcomes with a single numerical value. Descriptive statistical analysis of quantitative traits consisted of the arithmetic mean (xsr), standard deviation (SD), and, where needed, the median. The normality of the distribution of variables was tested with the Shapiro–Wilk test. Spearman's rho and Kendall tau rank coefficients were used for correlation analysis between measures. The correlation analyses have been supplemented with factor analysis. We found that the best results in terms of health care system performance were recorded in Russia, China, and Brazil. India and South Africa are noticeably worse. However, the entire group performs visibly worse than the developed countries. The health system outcomes appeared to correlate on a statistically significant scale with health expenditures per capita, governments involvement in health expenditures, GDP per capita, and industry share in GDP; however, these correlations are relatively weak, with the highest strength in the case of government's involvement in health expenditures and GDP per capita. Due to weak correlation with economic background, other factors may play a role in determining health system outcomes in BRICS countries. More research should be recommended to find them and determine to what extent and how exactly they affect health system outcomes.

Implementing evidence-informed deliberative processes in health technology assessment: a low income country perspective

The purpose of this paper is to discuss the potential feasibility and utility of evidence-informed deliberative processes (EPDs) in low income country (LIC) contexts. EDPs are implemented in high and middle income countries and thought to improve the quality, consistency, and transparency of decisions informed by health technology assessment (HTA). Together these would ultimately improve the legitimacy of any decision making process. We argue-based on our previous work and in light of the priority setting literature-that EDPs are relevant and feasible within LICs. The extreme lack of resources necessitates making tough decisions which may mean depriving populations of potentially valuable health technologies. It is critical that the decisions and the decision making bodies are perceived as fair and legitimate by the people that are most affected by the decisions. EDPs are well aligned with the political infrastructure in some LICs, which encourages public participation in decision making. Furthermore, many countries are committed to evidence-informed decision making. However, the application of EDPs may be hampered by the limited availability of evidence of good quality, lack of interest in transparency and accountability (in some LICs), limited capacity to conduct HTA, as well as limited time and financial resources to invest in a deliberative process. While EDPs would potentially benefit many LICs, mitigating the identified potential barriers would strengthen their applicability. We believe that implementation studies in LICs, documenting the contextualized enablers and barriers will facilitate the development of context specific improvement strategies for EDPs.

Health system strengthening-Reflections on its meaning, assessment, and our state of knowledge

Comprehensive reviews of health system strengthening (HSS) interventions are rare, partly because of lack of clarity on definitions of the term but also the potentially huge scale of the evidence. We reflect on the process of undertaking such an evidence review recently, drawing out suggestions on definitions of HSS and approaches to assessment, as well as summarising some key conclusions from the current evidence base. The key elements of a clear definition include, in our view, consideration of scope (with effects cutting across building blocks in practice, even if not in intervention design, and also tackling more than one disease), scale (having national reach and cutting across levels of the system), sustainability (effects being sustained over time and addressing systemic blockages), and effects (impacting on health outcomes, equity, financial risk protection, and responsiveness). We also argue that agreeing a framework for design and evaluation of HSS is urgent. Most HSS interventions have theories of change relating to specific system blocks, but more work is needed on capturing their spillover effects and their contribution to meeting overarching health system process goals. We make some initial suggestions about such goals, to reflect the features that characterise a "strong health system." We highlight that current findings on "what works" are just indicative, given the limitations and biases in what has been studied and how, and argue that there is need to rethink evaluation methods for HSS beyond finite interventions and narrow outcomes. Clearer concepts, frameworks, and methods can support more coherent HSS investment.

Availability and inequality in accessibility of health centre-based primary healthcare in Ethiopia

Background

Achieving fair access to healthcare and improving population health are crucial in all settings. Properly staffed and fairly distributed primary health care (PHC) facilities are prerequisites to ensure accessible healthcare services. Nevertheless, availability and accessibility issues are common public health concerns, especially in under-resourced countries including Ethiopia. Measuring inequalities in accessibility of healthcare resources guide policy decisions to improve PHC services and ultimately achieving universal health coverage (UHC).

Purpose

To assess availability and measure magnitude and trend of inequalities in accessibility of health centre-based PHC resources in Ethiopia during 2015 to 2017.

Methods

We conducted a cross-sectional population-based analysis of district-level data collected from 16^th December 2017 until 24^th May 2018. Afar, Dire-Dawa, and Tigray regions were purposefully included in the study to represent the four pastoralist/semi-pastoralist, three urban and four agrarian regions in Ethiopia, respectively. We used ratios, different inequality indices and Gini decomposition techniques to characterise the inequalities.

Results

In 2017, median of health centres (HCs) per 15,000 inhabitants and their Gini indices (GIs) for Afar, Dire-Dawa, and Tigray were 0.781, 0.566, 0.591 vs. 0.237, 0.280, 0.216 respectively. Median overall skilled health workers (SHWs) per 10,000 inhabitants were 5.250, 7.539, and 6.246, respectively. These accounted for 11.80%, 16.94% and 14.04% of the WHO target of 44.5 to achieve SDGs. The corresponding GIs for the regions were 0.347, 0.186 and 0.175. Despite a higher overall SHWs inequality in the urban districts of Tigray (GI = 0.301), only Tigray showed significant inequality reductions in GHE (p < 0.001) and in all categories of SHWs (p < 0.05).

Conclusions

Our analysis provided a clear picture of availability and inequalities in PHC resources across three regions in Ethiopia. Identifying contributing factors to low densities and high inequalities of SHWs may help improve PHC services nationwide, along with pathway towards UHC.

Understanding the implementation of Direct Health Facility Financing and its effect on health system performance in Tanzania: a non-controlled before and after mixed method study protocol

Background

Globally, good health system performance has resulted from continuous reform, including adaptation of Decentralisation by Devolution policies, for example, the Direct Health Facility Financing (DHFF). Generally, the role of decentralisation in the health sector is to improve efficiency, to foster innovations and to improve quality, patient experience and accountability. However, such improvements have not been well realised in most low- and middle-income countries, with the main reason cited being the poor mechanism for disbursement of funds, which remain largely centralised. The introduction of the DHFF programme in Tanzania is expected to help improve the quality of health service delivery and increase service utilisation resulting in improved health system performance. This paper describes the protocol, which aims to evaluate the effects of DHFF on health system performance in Tanzania.

Methods

An evaluation of the effect of the DHFF programme will be carried out as part of a nationwide programme rollout. A before and after non-controlled concurrent mixed methods design study will be employed to examine the effect of the DHFF programme implementation on the structural quality of maternal health, health facility governing committee governance and accountability, and health system responsiveness as perceived by the patients’ experiences. Data will be collected from a nationally representative sample involving 42 health facilities, 422 patient consultations, 54 health workers, and 42 health facility governing committees in seven regions from the seven zones of the Tanzanian mainland. The study is grounded in a conceptual framework centered on the Theory of Change and the Implementation Fidelity Framework. The study will utilise a mixture of quantitative and qualitative data collection tools (questionnaires, focus group discussions, in-depth interviews and documentary review). The study will collect information related to knowledge, acceptability and practice of the programme, fidelity of implementation, structural qualities of maternal and child health services, accountability, governance, and patient perception of health system responsiveness.

Discussion

This evaluation study will generate evidence on both the process and impact of the DHFF programme implementation, and help to inform policy improvement. The study is expected to inform policy on the implementation of DHFF within decentralised health system government machinery, with particular regard to health system strengthening through quality healthcare delivery. Health system responsiveness assessment, accountability and governance of Health Facility Government Committee should bring autonomy to lower levels and improve patient experiences. A major strength of the proposed study is the use of a mixed methods approach to obtain a more in-depth understanding of factors that may influence the implementation of the DHFF programme. This evaluation has the potential to generate robust data for evidence-based policy decisions in a low-income setting.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0400-3) contains supplementary material, which is available to authorized users.

Barriers and facilitators to the provision of optimal obstetric and neonatal emergency care and to the implementation of simulation-enhanced mentorship in primary care facilities in Bihar, India: a qualitative study

Background

Globally, an estimated 275,000 maternal deaths, 2.7 million neonatal deaths, and 2.6 million third trimester stillbirths occurred in 2015. Major improvements could be achieved by providing effective care in low- and middle-income countries, where the majority of these deaths occur. Mentoring programs have become a popular modality to improve knowledge and skills among providers in low-resource settings. Thus, a detailed understanding of interrelated factors affecting care provision and mentorship is necessary both to improve the quality of care and to maximize the impact of mentoring programs.

Methods

In partnership with the Government of Bihar, CARE India and PRONTO International implemented simulation-enhanced mentoring in 320 primary health clinics (PHC) across the state of Bihar, India from 2015 to 2017, within the context of the AMANAT mobile nurse mentoring program. Between June and August 2016, we conducted semi-structured interviews with 20 AMANAT nurse mentors to explore barriers and facilitators to optimal care provision and to implementation of simulation-enhanced mentorship in PHCs in Bihar. Data were analyzed using the thematic content approach.

Results

Mentors identified numerous factors affecting care provision and mentorship, many of which were interdependent. Such barriers included human resource shortages, nurse-nurse hierarchy, distance between labor and training rooms, cultural norms, and low skill level and resistance to change among mentees. In contrast, physical resource shortages, doctor-nurse hierarchy, corruption, and violence against providers posed barriers to care provision alone. Facilitators included improved skills and confidence among providers, inclusion of doctors in training, increased training frequency, establishment of strong mentor-mentee relationships, administrative support, and nursing supervision and feedback.

Conclusions

This study has identified many interrelated factors affecting care provision and mentorship in Bihar. The mentoring program was not designed to address several barriers, including resource shortages, facility infrastructure, corruption, and cultural norms. These require government support, community awareness, and other systemic changes. Programs may be adapted to address some barriers beyond knowledge and skill deficiencies, notably hierarchy, violence against providers, and certain cultural taboos. An in-depth understanding of barriers and facilitators is essential to enable the design of targeted interventions to improve maternal and neonatal survival in Bihar and related contexts.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-2059-8) contains supplementary material, which is available to authorized users.

Village Health Sanitation and Nutrition Committees: reflections on strengthening community health governance at scale in India

India’s National Health Mission constituted Village Health Sanitation and Nutrition Committees (VHSNCs) as a key mechanism for community health governance. Health committees provide citizens with the opportunity to shape health systems and policies. Yet much remains to be learnt on how best to sustain health committees as vehicles for community health governance at scale. This paper reflects on the authors’ experiences of introducing revised guidelines and an institutional support package for VHSNCs in two pilot settings in India and outlines lessons we learnt for sustaining community health governance at geographic scale. We describe the importance of ensuring norms for equitable participation, aligning committee rules with existing forms of decentralised government and providing key supports in terms of engaging NGOs as key implementation facilitators. Integration with rigid and unresponsive government administrative structures however remains a persistent challenge for scaling up health committees. With sustained financial support and strategic deployment of key personnel, VHSNCs could pave the way for more equitable and effective community participation in health governance at scale.

Primary health Centres' performance assessment measures in developing countries: review of the empirical literature

Background

It is universally accepted that primary healthcare is essential for achieving public health and that assessment of its performance is critical for continuous improvement. The World Health Organization’s (WHO’s) framework for performance assessment is a comprehensive global standard, but difficult to apply in developing countries because of financial and data constraints. This study aims to review the empirical literature on measures for Primary Health Centre (PHC) performance assessment in developing countries, and compare them for comprehensiveness with the aspects described by the WHO Framework.

Methods

Research articles published in English scientific journals between January 1979 and October 2016 were reviewed systematically. The reporting quality of the article and the quality of the measures were assessed with instruments adapted for the purpose of this study. Data was categorized and described.

Results

Fifteen articles were included in the study out of 4359 articles reviewed. Nine articles used quantitative methods, one article used qualitative methods exclusively and five used mixed methods. Fourteen articles had a good description of the measurement properties. None of the articles presented validity tests of the measures but eleven articles presented measures that were well established. Mostly studies included components of personnel competencies (skilled/ non-skilled) and centre performance (patient satisfaction/cost /efficiency).

Conclusions

In comparison to the WHO framework, the measures in the articles were limited in scope as they did not represent all service components of PHCs. Hence, PHC performance assessment should include system components along with relevant measures of personnel performance beyond knowledge of protocols. Existing measures for PHC performance assessment in developing countries need to be validated and concise measures for neglected aspects need to be developed.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3423-0) contains supplementary material, which is available to authorized users.